Aspiration biopsy cytology of metastatic extraskeletal myxoid chondrosarcoma and its cytologic differential diagnosis

Transabdominal fine needle aspiration biopsy of a metastatic myxoid chondrosarcoma in retroperitoneal spaces revealed amorphous mucoid material containing clusters of chondroblasts with round hyperchromatic nuclei and scanty cytoplasm, pleomorphic mesenchymal cells with round nuclei and vacuolated cytoplasm and groups of immature cartilaginous cells with single or double nuclei and fibrillar or filmy cytoplasm. The cytologic differential diagnosis between myxoid chondrosarcoma and other myxomatous tumors of bone and soft tissue is discussed.     

Fine needle aspiration in myxoid tumors of the soft tissues

Myxoid tumors of soft tissues constitute a histogenetically heterogeneous group of lesions, both benign and malignant, that show an overproduction of mucopolysaccharide substances. A correlative fine needle aspiration (FNA) cytologic and histologic study was performed on 16 such cases (3 intramuscular myxomas, 2 lipoblastomas, 6 myxoid liposarcomas, 4 myxoid malignant fibrous histocytomas [MFHs] and 1 extraskeletal myxoid chondrosarcoma), with electron microscopic examination of the aspirate in 4 cases. FNA of all tumors produced a gelatinous material. Smears from all but one of the tumors had a granular myxoid background substance that stained blue to blue-red with the Diff-Quik stain; the exception was the extraskeletal myxoid chondrosarcoma, whose smears stained intensely blue-red to red. On light microscopy, only lipomatous tumors had distinctive cells with diagnostic value: the lipoblasts. Although the arrangement of lipoblasts in lipoblastomas differed somewhat from that found in myxoid liposarcomas, clinical data were important for making a definitive diagnosis. Intramuscular myxomas generally showed a low cellularity composed of fibroblastlike cells with no cytologic atypia. Myxoid MFHs were composed of fibroblastlike cells and macrophagelike cells; the elongated cells with slight-to-moderate nuclear atypia predominated in tumors of low-grade malignancy, while polygonal or round cells with one or more nuclei and marked nuclear atypia predominated in high-grade tumors. Although extraskeletal myxoid chondrosarcoma was mainly differentiated from low-grade myxoid MFH by its metachromatic matrix, ultrastructural studies showed the distinctive distended cisternae with microtubular aggregates in the extraskeletal myxoid chondrosarcoma, thus contributing to the definitive diagnosis.     

Chondrosarcoma of the proximal femur with myxoid degeneration mistaken for chondromyxoid fibroma in a young adult. A case report

BACKGROUND: Fine needle aspiration cytology (FNAC) is effective in the diagnosis of bone tumors when combined with careful radiologic and clinical evaluation. However, cases where clinical or radiologic findings are atypical or unusual may lead to an erroneous diagnosis. CASE: A 19-year-old male presented with a pain in the left hip area that had been slowly progressive over a 10-month period. Clinical and radiologic findings suggested either giant cell tumor or chondroblastoma. The smeared aspiration specimen showed loosely cohesive, oval to round cells with moderate amounts of pale pink cytoplasm admixed with pinkish-blue, chondromyxoid material. The individual cells contained a single nucleus with evenly distributed, fine chromatin. A few osteoclastic giant cells were scattered in the smears. A cytologic diagnosis of myxoid lesion with a few giant cells, suspicious for chondromyxoid fibroma, was made. The diagnosis of chondrosarcoma was made by subsequent histologic examination. CONCLUSION: Absence of the usual clinicoradiologic features of chondrosarcoma combined with an unusual cytologic presentation in this case led to a misdiagnosis. In most centers, FNAC has achieved undisputed status as a diagnostic tool, and cytologic diagnosis often forms the basis of the therapeutic protocol. However, at some sites FNAC diagnosis is more problematic. Awareness of the limitations and pitfalls of FNAC is just as important as knowledge of the scope of FNAC in bone tumors. Tumors with chondromyxoid features provide particular difficulties.     

Cytodiagnosis of extraosseous mesenchymal chondrosarcoma of meninges: a case report

BACKGROUND: Extraosseous mesenchymal chondrosarcoma (MC) is a rare neoplasm. Most reports in the literature are based on histologic diagnosis. Cases diagnosed on the basis of cytologic features are few. CASE: A 30-year-old woman presented with complaints of headache, vomiting and swelling in the right temporal region for the previous 2 months. Fine needle aspiration (FNA) smears showed scant material consisting mainly of monomorphic small round cells with granular cytoplasm and central round nuclei lying in a background of myxoid matrix. Occasional giant cells were also seen. Cells were periodic acid-Schiff negative. One of the smears showed a tiny fragment of cartilaginous component. A provisional diagnosis of extraosseous MC was made. Peroperatively the mass was arising from meninges and the diagnosis was confirmed by histology. CONCLUSION: Extraosseous MC should be considered in FNA smears showing small round cells in a myxoid background. Demonstration of cartilage and a correlation of clinical presentation and imaging studies with cytologic findings are important.     

Fine needle aspiration cytology of extraskeletal chondrosarcoma

The cytologic presentation of a case of extraskeletal chondrosarcoma diagnosed by fine needle aspiration in a 57-year-old asymptomatic female is described. A mass detected on routine chest X ray and defined by CAT scan was subjected to a preoperative percutaneous fine needle aspiration under fluoroscopic guidance; a core biopsy was also obtained. Cytologic findings included pleomorphic malignant cells, with occasional spindle-shaped forms and binucleated and multinucleated cells having various degrees of nuclear atypia. The sarcomatous nature of this neoplasm was readily recognized in the cytologic material, although histologic and ultrastructural studies, which are also illustrated, were necessary to establish its specific histologic type. The biopsy was interpreted as a probable chondrosarcoma, and an exploratory laparotomy revealed a soft tissue tumor arising in the retroperitoneum. A diagnosis of soft tissue chondrosarcoma was rendered. In retrospect, the distinctive cytologic findings in the aspirated material suggest that extraskeletal chondrosarcoma should be considered in the differential diagnosis of soft tissue tumors.     

Potential sampling error in fine needle aspiration biopsy of dedifferentiated chondrosarcoma: a report of 4 cases

BACKGROUND: Dedifferentiated chondrosarcoma is a rare, poorly understood and often fatal sarcoma that usually manifests as a high grade, non-cartilage-producing sarcoma juxtaposed against a low grade chondrosarcoma. A correct diagnosis requires recognition of both components. In the absence of complete resection, rendering a specific diagnosis on small biopsy specimens, such as fine needle aspiration biopsy (FNAB), may be extraordinarily difficult. CASES: We retrospectively reviewed 4 cytology samples (3 primary, 1 metastatic) from 3 patients with dedifferentiated chondrosarcoma, initially analyzed by FNAB, emphasizing the potential for sampling error. Two women, aged 78 and 57 years, both of whom had prior histories of carcinoma, presented with lesions involving the right and left femur, respectively. One 27-year-old man with multiple osteochondromatosis developed a dedifferentiated chondrosarcoma of the left pelvis. Two primary cytologic specimens consisted of moderately cellular smears containing a spindled to polygonal, nonspecific, pleomorphic sarcoma unaccompanied by definite matrix material; 1 of these had a concomitant core needle biopsy (CNB), also demonstrating pleomorphic sarcoma. The third primary cytologic specimen revealed low grade chondrosarcoma, but a concomitant CNB showed only a high grade, non-matrix-producing sarcoma. The last patient developed a metastasis to the opposite femur; FNAB revealed a high grade spindle cell sarcoma. In none of the FNAB or CNB specimens were both low and high grade components of dedifferentiated chondrosarcoma recognized. However, the diagnosis was strongly suspected based on the clinical and radiographic findings. CONCLUSION: Due to sampling error, the diagnosis of dedifferentiated chondrosarcoma may be difficult to establish by cytologic examination alone. Clinical and radiographic correlation is essential for an accurate diagnosis.     

Retroperitoneal mesenchymal chondrosarcoma. Report of a case diagnosed by fine needle aspiration cytology

An unusual case of retroperitoneal mesenchymal chondrosarcoma diagnosed by fine needle aspiration (FNA) biopsy is described. CT-guided FNA of a mass arising in retroperitoneal soft tissues yielded an amorphous, myxoid material containing two distinct and separate populations of tumor cells. One was an undifferentiated, monomorphic, small cell component with granular cytoplasm and round central nuclei. The second population was an overtly malignant chondroid component scattered within an abundant myxoid matrix showing foamy cytoplasm, marked nuclear pleomorphism and frequent multi-nucleation. These cytologic findings were distinctive and similar to the histologic findings. The differential diagnosis and the possible pitfalls in the FNA diagnosis of this relatively rare tumor are discussed.     

Giant invasive pituitary adenoma extending into the sphenoid sinus and nasopharynx: report of a case with intraoperative cytologic diagnosis

BACKGROUND: Invasive pituitary adenomas involving the skull base are difficult to distinguish from other, more aggressive tumors. Intraoperaive diagnoses are crucial for deciding the course of treatment. CASE: A large mass extending from the sella turcica to the sphenoid sinus and nasopharynx was identified in a 42-year-old male. Because of the lack of endocrine abnormalities and lack of an apparent rise in pituitary hormones, preoperative diagnoses included chordoma, chondrosarcoma, meningioma and pituitary adenoma. Tumor fragments were easily squeezed into a thin layer of cells for cytologic specimens. Uniform, round tumor cells were arranged in minimally cohesive cell sheets and possessed regular, ovoid nuclei with a fine chromatin pattern and granular cytoplasm with prominent Golgi areas. The cytologic features indicated a probable diagnosis of pituitary adenoma and excluded other possibilities. Immunohistochemical demonstration of prolactin and ultrastructural features established the final diagnosis of prolactinoma. With the administration of bromocriptine, a large reduction in tumor size occurred. As compared to frozen sections, cytologic preparations are more effective for the intraoperative diagnosis of pituitary adenomas. Such neoplasms should always be included in the differential diagnosis of tumors involving the skull base.     

Imprint cytology of extraskeletal mesenchymal chondrosarcoma of the perineum: a case report

BACKGROUND: Extraskeletal mesenchymal chondrosarcoma (EMC) is an uncommon soft tissue tumor, occurring mainly in the lower limbs, meninges and retroperitoneum. EMC of the female genital tract is extremely rare, and the cytologic literature is scarce. CASE: A 43-year-old female with a growing perineal mass underwent excision of the tumor. Pathologic examination of the rumor revealed a characteristic two-cell pattern of primitive small cells and cartilaginous tissue. A diagnosis of EMC of the perineum was made. Imprint cytology from surgical material showed a cluster of small round cells with a focal hemangiopericytomalike arrangement and islets of cartilage. The cartilaginous cells reacted with S-100 protein immunocytochemically. CONCLUSION: The characteristic features of EMC, a hemangiopericytomalike arrangement of small cells and S-100-positive cartilaginous cells, may be helpful in diagnosing EMC and differentiating it from other perineal tumors.     

Cytologic features on needle aspiration of Wilms' tumor in an adult. A case report

A needle aspiration specimen from a left kidney mass in a 28-year-old woman was submitted for cytologic evaluation. Malignant cells were found, and the cytologic appearance was suggestive of a poorly differentiated sarcoma, with the possibility that it was a nephroblastoma. Important cytologic features of the needle aspiration specimen included round or oval blastomatous cells mixed with spindle or elongated sarcomatous cells, rare tubulelike formations of cells that appeared epithelial and a pronounced tumor diathesis. Histologic study of the nephrectomy specimen showed a Wilms' tumor, with anaplastic blastomatous and undifferentiated sarcomatous elements.     

Primary retroperitoneal seminoma diagnosed by fine needle aspiration biopsy. A case report

A fine needle aspiration biopsy specimen of a retroperitoneal mass was submitted for cytologic evaluation. Malignant cells were found, and the cytologic appearance was consistent with seminoma although the clinical possibilities included lymphoma and adenocarcinoma of the pancreas. Cytologic features of the needle biopsy specimen included uniform neoplastic malignant cells with round nuclei and nucleoli and clear or pale-staining cytoplasm. The cells were found singly or in groups of two or three cells. Lymphocytes were intermingled with the neoplastic cells.     

Fine needle aspiration cytology of primary extraskeletal myxoid chondrosarcoma. A case report

BACKGROUND: Extraskeletal myxoid chondrosarcoma is a rare soft tissue tumor of the extremities. Since it usually lacks obvious chondroid differentiation on light microscopy, it needs to be distinguished from other myxoid soft tissue sarcomas. CASE REPORT: The diagnosis of extraskeletal myxoid chondrosarcoma was made on fine needle aspiration in a patient with a swelling in the right calf. Cellular myxoid fragments having round to oval cells with grooved nuclei arranged in a cordlike pattern suggested chondroid differentiation. The diagnosis was confirmed by histopathology. CONCLUSION: Fine needle aspiration cytology can be diagnostic of extraskeletal myxoid chondrosarcoma even in the absence of obvious chondroid differentiation.     

Fine needle aspiration cytology of bone tumors

OBJECTIVE: To study the role of fine needle aspiration cytology (FNAC) in the diagnosis of bone tumors and its impact on therapeutic decisions. STUDY DESIGN: A group of 122 cases of bone tumor were evaluated by FNAC. Detailed diagnoses were compared with the available histology. RESULTS: Diagnostic accuracy of FNAC was 90.5% in this study. FNAC could differentiate between various round cell tumors such as Ewing's sarcoma and myeloma, among various giant cell-rich lesions of bone and between the benign and malignant chondroid bone tumors. Some uncommon variants were also correctly diagnosed. In metastatic bone tumors, the source of primary malignancy could not be indicated in the majority (52.9%) because of the poorly differentiated morphology. Osteoid or osteoid-like material was demonstrable in 63.6% cases of osteogenic sarcoma. A case of chondroblastic osteogenic sarcoma that was reported as chondrosarcoma was the only diagnostic error in the study. FNAC obviated the need of open biopsy in 63.8% patients, and therapeutic decisions were made according to the cytologic diagnoses. CONCLUSION: FNAC plays an important role in the early diagnosis of bone tumors by its accuracy, ease of use and rapidity and is helpful in making the therapeutic decisions.     

Cytologic, cytochemical, immunocytochemical and ultrastructural diagnosis of a sacrococcygeal chordoma in a fine needle aspiration biopsy specimen

The cytologic, cytochemical, immunocytochemical and ultrastructural findings on the aspirated material are presented for the case of a 57-year-old man with sacrococcygeal chordoma diagnosed by fine needle aspiration biopsy. Cytologically, two types of cellular elements were differentiated: medium-sized cells with few cytoplasmic vacuoles and classic physaliferous cells. Both types showed marked cytoplasmic positivity for keratin and S-100 protein; the absence of nuclear positivity in the physaliferous cells was notable. Ultrastructural study demonstrated the existence of true intracytoplasmic vacuoles and frequent rough endoplasmic reticulum-mitochondria complexes. The cytologic differential diagnosis with chondrosarcoma, myxoid liposarcoma, ependymoma and metastases of mucosecretory carcinomas is reviewed.     

Cytology of basaloid squamous carcinoma of the bronchus. A case report

BACKGROUND: The cytologic appearance of basaloid squamous carcinoma (BSC) arising in the lower respiratory tract has not been described very well because of its rarity. This article describes a surgical case of bronchial BSC and provides the first documentation of the sputum and imprint cytologic features of the tumor. CASE: A 74-year-old man presented with hemoptysis. An abnormal intrabronchial mass was revealed by computed tomography and bronchoscopy. Preoperative cytology and biopsy showed that the mass was composed of small, round, atypical cells, but correct diagnosis was difficult. Under a tentative diagnosis of small round cell carcinoma, a right lobectomy was performed. The resected tumor was composed of small cells showing peripheral palisading and partial epidermoid differentiation. There was no glandular differentiation. Focal necrosis was also noted. Immunohistochemical markers for smooth muscle and neuroendocrine cells were negative. The tumor was eventually diagnosed as BSC or basaloid carcinoma (BC) with squamous differentiation. CONCLUSION: It is important to recognize this disease, especially when undetermined small round cell carcinoma is noted in cytologic specimens, in order to properly assess prognosis. Cytologic detection of nuclear palisading of the neoplastic cells, one of the hallmarks of the disease, may be difficult, however, careful examination to reveal neoplastic cells showing squamous differentiation appears helpful for diagnosis.     

Primary rhabdomyosarcoma of the prostate. Diagnosis by needle biopsy and immunocytochemistry

Needle aspiration biopsy of the prostate in a patient who initially presented with multiple metastatic lesions in the lungs and a pleural effusion showed the presence of many malignant cells. These cells appeared either as noncohesive round and oval cells or as clusters. The cytologic impression that these were sarcoma cells was confirmed by subsequent histologic and immunochemical studies. By correlating the cytologic, histologic and immunochemical findings with the clinical findings, it was possible to determine that the primary site of the tumor in this patient was the prostate. Our experience in this case suggests that air-dried smears stained with Romanowsky stains are suitable and useful for cytodiagnosis.     

Cytodiagnosis of central neurocytoma in intraoperative preparations

OBJECTIVE: To assess the cytologic features in smear preparations of 3 central neurocytomas. STUDY DESIGN: Three patients with central neurocytoma underwent intraoperative frozen section diagnoses, and the cytologic evaluations are presented. RESULTS: The smears typically showed cellular tumors composed of isomorphous, round cells. The tumor cells showed ill-defined cytoplasm oval nuclei with finely granular chromatin and micronucleoli. A fibrillary matrix in the background was noted in all cases. The tumor in the 20-year-old patient exhibited numerous giant cells with phyagocytosed hemosiderin granules between small, round tumor cells. Permanent sections, immunohistochemistry and electron microscopy confirmed that all cases were central neurocytomas. CONCLUSION: Central neurocytomas can be diagnosed reliably using combined cytologic preparations and frozen sections. The appearance of numerous macrophages that phagocytose hemosiderin between neoplastic cells should also be considered characteristic of the cytomorphology of central neurocytomas.     

Polymorphous low grade adenocarcinoma of the salivary gland. Diagnosis by fine needle aspiration cytology

OBJECTIVE: To describe the fine needle aspiration cytology findings of polymorphous low grade adenocarcinoma of the salivary gland. STUDY DESIGN: The authors reviewed the cytologic findings of 5 cases of polymorphous low grade adenocarcinoma. All cases were confirmed by histologic examination. RESULTS: All cases showed similar cytologic findings. The smears had high cellularity with a population of mixed epithelial and myoepithelial cells. These cells formed branching papillae, sheets and clusters. The epithelial cells were uniform, with round to ovoid nuclei; absent or inconspicuous nucleoli; and a moderate amount of dense cytoplasm. Occasionally the cells formed spherical structures containing hyaline globules. Myxoid matrix, either dispersed in the background or interspersed with the cellular elements, was also seen often. CONCLUSION: Polymorphous low grade adenocarcinoma should be cytologically differentiated from adenoid cystic carcinoma, monomorphic adenoma and pleomorphic adenoma. Recognition of subtle cytologic features. may be useful in the differential diagnosis.